Are serial CA 19-9 kinetics helpful in predicting survival in patients with advanced or metastatic pancreatic cancer treated with gemcitabine and cisplatin?

BACKGROUND: Serial kinetics of serum CA 19-9 levels have been reported to reflect response and survival in patients with pancreatic cancer undergoing surgery, radiotherapy, and chemotherapy. We prospectively studied serial kinetics of serum CA 19-9 levels of patients with locally advanced or metastatic disease treated with gemcitabine and cisplatin. PATIENTS AND METHODS: Enrolled in the study were 87 patients (female/male = 26/61; stage III/IV disease = 24/63). Patients received gemcitabine 1,000 mg/m(2) on days 1, 8, and 15 plus cisplatin 50 mg/m(2) on days 1 and 15, every 4 weeks. Serum samples were collected at the onset of chemotherapy and before the start of a new treatment cycle (day 28). RESULTS: 77 of 87 patients (88.5%) with initially elevated CA 19-9 levels were included for evaluation. According to imaging criteria, 4 (5.2%) achieved a complete remission and 11 (14.3%) achieved partial remission, yielding an overall response rate of 19.5%. 43 (55.8%) patients were CA 19-9 responders, defined by a > or = 50% decrease in CA 19-9 serum levels within 2 months after treatment initiation. Except for one, all patients who had responded by imaging criteria (n = 14) fulfilled the criterion of a CA 19-9 responder. Despite being characterized as non-responders by CT-imaging criteria (stable/progressive disease), 29 patients were classified as CA 19-9 responders (positive predictive value 32.5%). Independent of the response evaluation by CT, CA 19-9 responders survived significantly longer than CA 19-9 nonresponders (295 d; 95% CI: 285-445 vs. 174 d; 95% CI: 134-198; p = 0.022). CONCLUSION: CA 19-9 kinetics in serum serve as an early and reliable indicator of response and help to predict survival in patients with advanced pancreatic cancer receiving effective treatment with gemcitabine and cisplatin.

[Esophageal carcinoma: guidelines in surgical therapy]. / Oesophaguskarzinom: Die Leitlinien der chirurgischen Therapie.

According to oncological criteria, resections for esophageal cancer require a combined abdominal and thoracic approach and should include two-field lymphadenectomy. The value of a three-field lymphadenectomy is still under discussion, because this extended lymph node dissection may provide better survival rates for patients with proximal esophageal cancer and positive lymph node stages on the one hand, but will cause increased morbidity, on the other. A neoadjuvant radio- and/or chemotherapy allows down staging in about 50% of patients with advanced esophageal cancer (stage IIB, III or IV). This leads to higher resectability rates, but is not necessarily associated with better survival rates.

Cerulein-induced acute pancreatitis in rats--does bacterial translocation occur via a transperitoneal pathway?

Bacterial infectious complications are the most common cause of morbidity and mortality associated with acute pancreatitis. Most pathogens are common gastrointestinal flora, indicating that the gut is the source of pancreatitis-related infections. However, the route whereby the microorganisms reach distant organs remains speculative. We tested the hypothesis that spread of bacteria occurs via a transperitoneal pathway. Acute interstitial pancreatitis (AIP) was induced in antibiotic (gentamicin, bacithracin, neomycin)-decontaminated rats by intravenous infusion of cerulein. Effects of pancreatic necrosis (PN) were studied in rats that received additional injections into the peritoneal cavity of pancreatic tissue obtained from donor rats. The rats were inoculated with Escherichia coli (O2:KN:H18) resistant to the antibiotics used for decontamination either orally (10(12) microorganisms; experiment I) or intraperitoneally (10(8) microorganisms; experiment II). Moreover, the rat peritoneal cavity wash was inoculated with 10(8) E. coli in vitro (experiment III). In rats with AIP and PN, recovery of the bacteria from liver, spleen, pancreas, lung, and blood following oral inoculation demonstrated that acute pancreatitis promotes bacterial translocation from the gut. The absence of E. coli in these organs following intraperitoneal inoculation showed that the bacteria do not spread from the peritoneal cavity. Rats with PN cleared E. coli from the peritoneal cavity in a shorter period than rats with AIP and controls (5 vs. 7 and 8 days; p < 0.05). The multiplication rate of E. coli in peritoneal cavity wash was lower in rats with PN than in rats with AIP and controls (p < 0.01). We conclude that (1) translocation of E. coli from the gut during cerulein-induced acute pancreatitis occurs via nonperitoneal pathways, (2) the peritoneal cavity acts as a trap for the bacteria rather than a source of bacterial seeding, and (3) PN impairs survival of E. coli in the peritoneal cavity via inhibition of the bacterial multiplication in this model.

Santorini's duct--risk factor for acute pancreatitis or protective morphologic variant? Experiments in rabbits.

BACKGROUND AND AIMS: Gallstone pancreatitis is assumed to result from stone passage through the choledochoduodenal junction. Stone impactions may either result in the obstruction of the pancreatic duct or occur below the confluence of the biliary tract and the pancreatic duct and, thus, may favour bile reflux into the pancreatic duct. We studied effects of a patent Santorini's duct upon secretory flow and pancreas morphology under both conditions. METHODS: A catheter in the distal rabbit pancreatic duct created a second outlet for pancreatic juice and, thus, mimicked a patent Santorini's duct. A second catheter was introduced into the proximal pancreatic duct and into the common bile duct. This catheter mimicked a common channel behind a papillary obstruction. Clamping of this catheter mimicked a stone obstruction of the pancreatic duct. A catheter in the cystic duct allowed for the infection of bile with 10(7) Escherichia coli bacteria/ml. The flow direction of bile and pancreatic juice was directly observed. Pancreatic histology was analysed after 24 h. RESULTS: Pancreatic duct obstruction produced an oedema of the gland. Creation of a patent Santorini's duct prevented development of the histological changes caused by pancreatic duct obstruction. In rabbits in which a common channel obstruction was mimicked, Santorini's duct produced flow of bile along the pancreatic duct system. Flow of sterile bile along the duct did not cause pancreatic inflammatory lesions. Bile that was infected with E. coli bacteria produced an acute interstitial-oedematous pancreatitis. CONCLUSIONS: (1) A patient Santorini's duct protects the gland from the effects of main pancreatic duct obstruction; (2) Santorini's duct promotes biliary pancreatic reflux during obstruction of the common channel and subsequent development of pancreatitis caused by infected choledochal secretions; (3) Santorini's duct may thus be both a protective morphological variant and a risk factor for pancreatitis dependent upon the site of stone impaction within the choledochoduodenal junction.

Cardiac tamponade--a rare complication in acute pancreatitis.

A patient with recurrent acute pancreatitis developed pericardial effusion and cardiac tamponade. His systolic blood pressure fell to 70 mmHg and sinus tachycardia (150/min) developed. The central venous pressure rose from 3 cm H2O to 27 cm H2O. A chest radiograph showed an enlargement of the cardiac shadow. Pericardial paracentesis was performed and 300 ml fluid was aspirated. This produced rapid clinical improvement. The literature related to this uncommon complication is reviewed and possible pathogenetic mechanisms are discussed.

Does high pancreatic duct pressure compromise the duct mucosal barrier function to pancreatic exocrine proteins?

The effect of duct pressure on the barrier function of the pancreatic duct mucosa to both activated and nonactivated pancreatic exocrine enzymes was studied in a feline model. The cat main pancreatic duct was perfused from the tail to the head of the gland with rat pancreatic juice at high duct pressure (40 cm H2O). In a first experiment, nonactivated pancreatic juice was perfused. Analysis of the juice for loss of fluid volume (measurement by weight) and for loss of individual proteins (two-dimensional isoelectric focusing/sodium dodecyl sulphate gel electrophoresis, reversed phase-high performance liquid chromatography) after duct passage showed that pancreatic secretions were completely recovered from the duct lumen. In another experiment, applying the same pressure, the duct was perfused with activated pancreatic juice. Morphologic analysis showed a preservation of the pancreatic duct mucosal integrity immediately after duct perfusion and absence of pancreatic inflammatory lesions 24 h after duct passage. We conclude that the pancreatic duct mucosa is impermeable to the leakage of pancreatic exocrine proteins from the duct lumen at duct pressure < or = 40 cm H2O. Flow of activated pancreatic juice along the pancreatic duct at duct pressure < or = 40 cm H2O does not cause acute pancreatitis. These data do not support the hypothesis that leakage of pancreatic juice from the duct lumen caused by high intraductal pressure due to duct obstruction initiates acute pancreatitis.

[Value of endorectal sonography in the follow-up of patients treated surgically for rectum carcinoma]. / Die Wertigkeit der endorektalen Sonographie in der Tumornachsorge bei operiertem Rektumkarzinom.

This prospective study included 80 patients in routine follow-up examinations after rectal cancer treatment. We performed anamnesis, clinical examination, total colonoscopy and endorectal sonography and tested the level of tumour markers CEA and CA 19-9. In 10 cases we detected local cancer recurrence of the rectal tumour. In 8 cases tumour markers were pathologically raised. Endoscopy detected the local recurrence in 4 patients only. Endorectal US was able to detect all of the recurrence cases. A histological confirmation was possible by EUS-guided needle biopsy in all cases. We were able to perform R 0-re-resection with the hope of curing in 4 patients out of 10 recurrence cases. Only endorectal US was able to detect two of those 4 recurrent tumours. In the follow-up of rectal cancer endorectal US seems to be a highly sensitive examination that may raise the number of re-resection with the hope of curing after rectal cancer treatment.

Development and perspectives of experimental pancreas transplantation in the rat.

Whole organ pancreas transplantation in the rat was first described by Sun Lee in 1972. Since that time the basic technique has been modified in several ways and this model can now be used for a variety of experiments. Various techniques for transplantation and representative results of functional and immunological experiments are summarized.

[Air pathogen content in the intensive care station of a pediatric clinic]. / Uber den Luftkeimgehalt auf der Intensivstation einer Kinderklinik.

The bacterial count of air in 2 intensive care units was examined by membrane filter technique (MD 2 model SM 167 21). 88 samples of room air and 296 samples of incubator air were studied. The occurrence of bacteria, especially gramnegative rods, was investigated in incubators and in respirators. The results were related to bacterial counts in tracheal secretions from newborns during long term ventilation. The bacterial content of air in the incubators were relatively low. The results were different in two intensive care units leading to changes in the hygienic routine of intensive care units.